Provider Demographics
NPI:1720614316
Name:DESMOND, SHAE LESLIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SHAE
Middle Name:LESLIE
Last Name:DESMOND
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4870 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-4432
Mailing Address - Country:US
Mailing Address - Phone:317-670-3988
Mailing Address - Fax:
Practice Address - Street 1:4870 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-4432
Practice Address - Country:US
Practice Address - Phone:317-670-3988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22007084A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist